Title: Safe Use of Opioids - Concurrent PrescribingFHIR Id: SafeUseofOpioidsConcurrentPrescribingFHIR Download cql: SafeUseofOpioidsConcurrentPrescribingFHIR.cql Version: 0.1.000 Url: Safe Use of Opioids - Concurrent PrescribingFHIR short-name identifier: CMS506FHIR version-independent identifier: urn:uuid:95d529af-66b4-4cfd-bc1f-f43704dc47ad version-specific identifier: urn:uuid:4adc0abd-6de0-42e7-ab1a-37f53d3ddd1f endorser (NQF) identifier: 3316e publisher (CMS) identifier: 506FHIR Effective Period: 2024-01-01 ..2024-12-31 Status: draft Date: 2023-08-17 18:49:02+0000 Approval Date: 2023-08-18 Last Review Date: 2023-08-18 Name: SafeUseofOpioidsConcurrentPrescribingFHIR Publisher: Centers for Medicare & Medicaid Services (CMS) Author: Mathematica: https://www.mathematica.org/ Description: Proportion of inpatient hospitalizations for patients 18 years of age and older prescribed, or continued on, two or more opioids or an opioid and benzodiazepine concurrently at discharge Use Context: code value program Purpose: UNKNOWN Copyright: Limited proprietary coding is contained in the Measure specifications for user convenience. Users of proprietary code sets should obtain all necessary licenses from the owners of the code sets. Mathematica disclaims all liability for use or accuracy of any third party codes contained in the specifications. CPT(R) contained in the measure specifications is copyright 2004-2022 American Medical Association. LOINC(R) copyright 2004-2022 Regenstrief Institute, Inc. This material contains SNOMED Clinical Terms(R) (SNOMED CT[R]) copyright 2004-2022 International Health Terminology Standards Development Organisation. ICD-10 copyright 2022 World Health Organization. All Rights Reserved. Disclaimer: These performance measures are not clinical guidelines, do not establish a standard of medical care, and have not been tested for all potential applications. THE MEASURES AND SPECIFICATION ARE PROVIDED AS IS WITHOUT WARRANTY OF ANY KIND. Due to technical limitations, registered trademarks are indicated by (R) or [R] and unregistered trademarks are indicated by (TM) or [TM]. Rationale: Unintentional opioid overdose fatalities have become a major public health concern in the United States (Rudd et al., 2016). Reducing the number of unintentional overdoses has become a priority for numerous federal organizations including, but not limited to, the Centers for Disease Control and Prevention (CDC), the Federal Interagency Workgroup for Opioid Adverse Drug Events, and the Substance Abuse and Mental Health Services Administration. Concurrent prescriptions of opioids or opioids and benzodiazepines places patients at a greater risk of unintentional overdose due to the increased risk of respiratory depression (Dowell, Haegerich, & Chou, 2016 and Dowell, Ragan, Jones, Baldwin, & Chou, 2022). An analysis of national prescribing patterns shows that more than half of patients who received an opioid prescription in 2009 had filled another opioid prescription within the previous 30 days (National Institute on Drug Abuse, 2011). Studies of multiple claims and prescription databases have shown that between 5%-15% of patients receive concurrent opioid prescriptions and 5%-20% of patients receive concurrent opioid and benzodiazepine prescriptions across various settings (Liu et al., 2013; Mack et al., 2015, Park et al., 2015). Patients who have multiple opioid prescriptions have an increased risk for overdose (Jena et al., 2014). Rates of fatal overdose are ten times higher in patients who are co-dispensed opioid analgesics and benzodiazepines than opioids alone (Dasgupta et al., 2015). The number of opioid overdose deaths involving benzodiazepines increased 14% on average each year from 2006 to 2011, while the number of opioid analgesic overdose deaths not involving benzodiazepines did not change significantly (Jones & McAninch, 2015). Furthermore, concurrent use of benzodiazepines with opioids was prevalent in 31%-51% of fatal overdoses (Dowell, Haegerich, & Chou, 2016). One study found that eliminating concurrent use of opioids and benzodiazepines could reduce the risk of opioid overdose-related emergency department (ED) and inpatient visits by 15% and potentially could have prevented an estimated 2,630 deaths related to opioid painkiller overdoses in 2015 (Sun et al., 2017). A study on The Opioid Safety Initiative in the Veterans Health Administration (VHA), which includes an opioid and benzodiazepine concurrent prescribing measure that this measure is based on, was associated with a decrease of 20.67% overall and 0.86% patients per month (781 patients per month) receiving concurrent benzodiazepine with an opioid among all adult VHA patients who filled outpatient opioid prescriptions from October 2012 to September 2014 (Lin et al., 2017). Adopting a measure that calculates the proportion of patients with two or more opioids or opioids and benzodiazepines concurrently has the potential to reduce preventable mortality and reduce the costs associated with adverse events related to opioid use by (1) encouraging providers to identify patients with concurrent prescriptions of opioids or opioids and benzodiazepines and (2) discouraging providers from prescribing two or more opioids or opioids and benzodiazepines concurrently. Clinical recommendation statement: The CDC Clinical Practice Guideline for Prescribing Opioids for Pain — United States, 2022 recommends that clinicians should: “[Use strategies minimizing] opioid use…for both opioid-naïve and opioid-tolerant patients with acute pain when possible. If patients receiving long-term opioid therapy require additional medication for acute pain, nonopioid medications should be used when possible.” ”Use particular caution when prescribing opioid pain medication and benzodiazepines concurrently." “Review increased risks for respiratory depression when opioids are taken with benzodiazepines, other sedatives, alcohol, nonprescribed or illicit drugs (e.g., heroin), or other opioids (see Recommendations 8 and 11)” “Closely monitor patients who are unable to taper and who continue on high-dose or otherwise high-risk opioid regimens (e.g., opioids prescribed concurrently with benzodiazepines) and should work with patients to mitigate overdose risk (e.g., by providing overdose education and naloxone) (see Recommendation 8).” "Discuss information from the PDMP with the patient and confirm that the patient is aware of any additional prescriptions.” “Discuss safety concerns, including increased risk for respiratory depression and overdose, with patients found to be receiving overlapping prescription opioids from multiple clinicians who are not coordinating the patient’s care or patients who are receiving medications that increase risk when combined with opioids (e.g., benzodiazepines) (see Recommendation 11), and offer naloxone (see Recommendation 8). "Discuss safety concerns with other clinicians who are prescribing controlled substances for the patient. Ideally, clinicians should first discuss concerns with the patient and inform them that they plan to coordinate care with their other clinicians to improve the patient’s safety.” In addition to the 2022 CDC Clinical Practice Guideline for Prescribing Opioids for Pain, opioid prescribing guidelines issued by various state agencies and professional societies for various settings agree with the recommendation to avoid concurrently prescribing opioids (American Academy of Emergency Medicine and Washington Agency Medical Directors’ Group (WAMDG)), and opioids and benzodiazepines (WAMDG, American Society of Interventional Pain Physicians, and New York City Department Of Health and Mental Hygiene) whenever possible as the combination of these medications may potentiate opioid-induced respiratory depression. Guidance (Usage): Clinician judgement, clinical appropriateness, or both may indicate concurrent prescribing of two unique opioids or an opioid and benzodiazepine is medically necessary, thus the measure is not expected to have a zero rate. Inpatient hospitalizations with discharge medications of a new or continuing opioid or a new or continuing benzodiazepine prescription should be included in the initial population. Inpatient hospitalizations with discharge medications of two or more new or continuing opioids or new or continuing opioid and benzodiazepine resulting in concurrent therapy at discharge should be included in the numerator. Each benzodiazepine and opioid included on the medication discharge list is considered a unique prescription. The denominator population includes patients with inpatient hospitalizations and patients from Acute Hospital Care at Home programs, who are treated and billed as inpatients but receive care in their home. This eCQM is an episode-based measure. An episode is defined as each inpatient hospitalization or encounter that ends during the measurement period. This FHIR-based measure has been derived from the QDM-based measure: CMS506v6. Please refer to the HL7 QI-Core Implementation Guide (http://hl7.org/fhir/us/qicore/index.html) for more information on QI-Core and mapping recommendations from QDM to QI-Core 4.1.1 (http://hl7.org/fhir/us/qicore/qdm-to-qicore.html). Population Criteria: 64345d297c12bd4a0fdf28b2 Initial Population: Inpatient hospitalizations (inpatient stay less than or equal to 120 days) that end during the measurement period, where the patient is 18 years of age and older at the start of the encounter and prescribed one or more new or continuing opioid or benzodiazepine at discharge Denominator: Initial Population Denominator Exclusion: Inpatient hospitalizations where patients have cancer that begins prior to or during the encounter or are ordered or are receiving palliative or hospice care (including comfort measures, terminal care, and dying care) during the hospitalization or in an emergency department encounter or observation stay immediately prior to hospitalization, patients discharged to another inpatient care facility, and patients who expire during the inpatient stay. Numerator: Inpatient hospitalizations where the patient is prescribed or continuing to take two or more opioids or an opioid and benzodiazepine at discharge Numerator Exclusion: None Denominator Exception: None Supplemental Data Guidance : Supplemental Data Elements: SDE Ethnicity SDE Payer SDE Race SDE Sex Libraries: SafeUseofOpioidsConcurrentPrescribingFHIR Related Artifact Dependencies: Library/SupplementalDataElements|3.4.000 Library/CQMCommon|1.4.000 Library/FHIRHelpers|4.3.000 Library/FHIRHelpers|4.3.000 Library/QICoreCommon|1.5.000 Library/FHIRHelpers|4.3.000 Library/FHIRHelpers|4.3.000 Library/QICoreCommon|1.5.000 MedicationRequest Category Codes Condition Category Codes US Core Condition Category Extension Codes Condition Clinical Status Codes Encounter Inpatient Schedule II and III Opioid Medications Schedule IV Benzodiazepines Payer All Primary and Secondary Cancer Palliative or Hospice Care Observation Services Emergency Department Visit Discharge To Acute Care Facility Hospice Care Referral or Admission Patient Expired Parameters: name use min max type Measurement Period In 0 1 Period SDE Sex Out 0 1 Coding Numerator Out 0 * Resource Denominator Out 0 * Resource SDE Payer Out 0 * Resource Initial Population Out 0 * Resource SDE Ethnicity Out 0 1 Resource Denominator Exclusion Out 0 * Resource SDE Race Out 0 1 Resource DataRequirements: Type Elements Valueset Name Valueset Patient(QICorePatient) Patient(http://hl7.org/fhir/Patient) gender gender.value birthDate birthDate.value Encounter(QICoreEncounter) type status status.value period Encounter Inpatient Encounter Inpatient Patient(QICorePatient) Encounter(QICoreEncounter) type status status.value period Encounter Inpatient Encounter Inpatient MedicationRequest(QICoreMedicationRequest) medication Schedule II, III Opioid Medications Schedule II and III Opioid Medications MedicationRequest(QICoreMedicationRequest) medication Schedule II, III Opioid Medications Schedule II and III Opioid Medications MedicationRequest(QICoreMedicationRequest) medication Schedule IV Benzodiazepines Schedule IV Benzodiazepines MedicationRequest(QICoreMedicationRequest) medication status status.value intent intent.value authoredOn authoredOn.value Schedule IV Benzodiazepines Schedule IV Benzodiazepines Encounter(QICoreEncounter) type status status.value period Encounter Inpatient Encounter Inpatient MedicationRequest(QICoreMedicationRequest) medication status status.value intent intent.value authoredOn authoredOn.value Schedule IV Benzodiazepines Schedule IV Benzodiazepines Encounter(QICoreEncounter) type status status.value period Encounter Inpatient Encounter Inpatient Encounter(QICoreEncounter) type status status.value period Encounter Inpatient Encounter Inpatient Coverage(QICoreCoverage) type period Payer Type Payer uri(http://hl7.org/fhir/uri) value Patient(QICorePatient) url extension Patient(QICorePatient) url extension Condition(http://hl7.org/fhir/Condition) clinicalStatus Condition(QICoreCondition) id id.value ServiceRequest(QICoreServiceRequest) code Palliative or Hospice Care Palliative or Hospice Care Procedure(QICoreProcedure) code Palliative or Hospice Care Palliative or Hospice Care Patient(QICorePatient) Encounter(QICoreEncounter) type status status.value period Observation Services Observation Services Encounter(QICoreEncounter) type status status.value period Emergency Department Visit Emergency Department Visit Encounter(QICoreEncounter) type status status.value period Observation Services Observation Services Encounter(QICoreEncounter) type status status.value period Emergency Department Visit Emergency Department Visit Condition(QICoreCondition) code All Primary and Secondary Cancer All Primary and Secondary Cancer Patient(QICorePatient) url extension Patient(QICorePatient) url extension Coverage(QICoreCoverage) type period Payer Type Payer Patient(QICorePatient) url extension Patient(QICorePatient) url extension Direct Reference Codes: display code system Community community http://terminology.hl7.org/CodeSystem/medicationrequest-category Discharge discharge http://terminology.hl7.org/CodeSystem/medicationrequest-category Problem List Item problem-list-item http://terminology.hl7.org/CodeSystem/condition-category Health Concern health-concern http://hl7.org/fhir/us/core/CodeSystem/condition-category active http://terminology.hl7.org/CodeSystem/condition-clinical recurrence http://terminology.hl7.org/CodeSystem/condition-clinical relapse http://terminology.hl7.org/CodeSystem/condition-clinical Logic Definitions: Group Scoring Population Criteria Expression 64345d297c12bd4a0fdf28b2 Group scoring: proportion Initial Population define "Initial Population": "Inpatient Encounters with an Opioid or Benzodiazepine at Discharge" Denominator define "Denominator": "Initial Population" Denominator Exclusion define "Denominator Exclusion": /*Excludes encounters of patients with cancer or who are receiving palliative or hospice care at the time of the encounter*/ "Inpatient Encounters with an Opioid or Benzodiazepine at Discharge" InpatientEncounter where exists ( [Condition: "All Primary and Secondary Cancer"] Cancer where ( Cancer.isProblemListItem ( ) or Cancer.isHealthConcern ( ) ) and Cancer.isActive ( ) and Cancer.prevalenceInterval ( ) overlaps InpatientEncounter.period ) or exists ( ( InpatientEncounter.encounterDiagnosis ( ) ) InpatientEncounterDiagnosis where InpatientEncounterDiagnosis.code in "All Primary and Secondary Cancer" ) or exists ( "Intervention Palliative or Hospice Care" PalliativeOrHospiceCare where Coalesce(PalliativeOrHospiceCare.performed.toInterval(), PalliativeOrHospiceCare.authoredOn.toInterval()) during day of CQMCommon."HospitalizationWithObservation" ( InpatientEncounter ) ) or ( InpatientEncounter.hospitalization.dischargeDisposition in "Discharge To Acute Care Facility" or InpatientEncounter.hospitalization.dischargeDisposition in "Hospice Care Referral or Admission" or InpatientEncounter.hospitalization.dischargeDisposition in "Patient Expired" ) Numerator define "Numerator": /*Encounters of patients prescribed two or more opioids or an opioid and benzodiazepine at discharge.*/ ( "Inpatient Encounter with Age Greater than or Equal to 18" InpatientEncounter where ( Count("Opioid at Discharge" Opioids return distinct Opioids.medication ) >= 2 ) ) union ( "Inpatient Encounter with Age Greater than or Equal to 18" InpatientEncounter with "Opioid at Discharge" OpioidsDischarge such that OpioidsDischarge.authoredOn during InpatientEncounter.period with "Benzodiazepine at Discharge" BenzodiazepinesDischarge such that BenzodiazepinesDischarge.authoredOn during day of InpatientEncounter.period ) Numerator Exclusion None Denominator Exception None Library Name Name SupplementalDataElements SDE Sex define "SDE Sex": case when Patient.gender = 'male' then Code { code: 'M', system: 'http://hl7.org/fhir/v3/AdministrativeGender', display: 'Male' } when Patient.gender = 'female' then Code { code: 'F', system: 'http://hl7.org/fhir/v3/AdministrativeGender', display: 'Female' } else null end Library Name Name SafeUseofOpioidsConcurrentPrescribingFHIR SDE Sex define "SDE Sex": SDE."SDE Sex" Library Name Name CQMCommon Inpatient Encounter define "Inpatient Encounter": [Encounter: "Encounter Inpatient"] EncounterInpatient where EncounterInpatient.status = 'finished' and EncounterInpatient.period ends during day of "Measurement Period" Library Name Name SafeUseofOpioidsConcurrentPrescribingFHIR Inpatient Encounter with Age Greater than or Equal to 18 define "Inpatient Encounter with Age Greater than or Equal to 18": CQMCommon."Inpatient Encounter" InpatientHospitalEncounter where AgeInYearsAt(date from start of InpatientHospitalEncounter.period) >= 18 Library Name Name SafeUseofOpioidsConcurrentPrescribingFHIR Opioid at Discharge define "Opioid at Discharge": ( [MedicationRequest: "Schedule II & III Opioid Medications"] OpioidMedications where ( OpioidMedications.isCommunity ( ) or OpioidMedications.isDischarge ( ) ) ) OpioidDischargeMedication where OpioidDischargeMedication.status in { 'active', 'completed' } and OpioidDischargeMedication.intent = 'order' Library Name Name SafeUseofOpioidsConcurrentPrescribingFHIR Benzodiazepine at Discharge define "Benzodiazepine at Discharge": ( [MedicationRequest: medication in "Schedule IV Benzodiazepines"] BenzoMedications where ( BenzoMedications.isCommunity ( ) or BenzoMedications.isDischarge ( ) ) ) BenzodiazepineDischargeMedication where BenzodiazepineDischargeMedication.status in { 'active', 'completed' } and BenzodiazepineDischargeMedication.intent = 'order' Library Name Name SafeUseofOpioidsConcurrentPrescribingFHIR Numerator define "Numerator": /*Encounters of patients prescribed two or more opioids or an opioid and benzodiazepine at discharge.*/ ( "Inpatient Encounter with Age Greater than or Equal to 18" InpatientEncounter where ( Count("Opioid at Discharge" Opioids return distinct Opioids.medication ) >= 2 ) ) union ( "Inpatient Encounter with Age Greater than or Equal to 18" InpatientEncounter with "Opioid at Discharge" OpioidsDischarge such that OpioidsDischarge.authoredOn during InpatientEncounter.period with "Benzodiazepine at Discharge" BenzodiazepinesDischarge such that BenzodiazepinesDischarge.authoredOn during day of InpatientEncounter.period ) Library Name Name SafeUseofOpioidsConcurrentPrescribingFHIR Inpatient Encounters with an Opioid or Benzodiazepine at Discharge define "Inpatient Encounters with an Opioid or Benzodiazepine at Discharge": "Inpatient Encounter with Age Greater than or Equal to 18" InpatientEncounter with ( "Opioid at Discharge" union "Benzodiazepine at Discharge" ) OpioidOrBenzodiazepineAtDischarge such that OpioidOrBenzodiazepineAtDischarge.authoredOn during day of InpatientEncounter.period Library Name Name SafeUseofOpioidsConcurrentPrescribingFHIR Initial Population define "Initial Population": "Inpatient Encounters with an Opioid or Benzodiazepine at Discharge" Library Name Name SafeUseofOpioidsConcurrentPrescribingFHIR Denominator define "Denominator": "Initial Population" Library Name Name SupplementalDataElements SDE Payer define "SDE Payer": [Coverage: type in "Payer Type"] Payer return { code: Payer.type, period: Payer.period } Library Name Name SafeUseofOpioidsConcurrentPrescribingFHIR SDE Payer define "SDE Payer": SDE."SDE Payer" Library Name Name SupplementalDataElements SDE Ethnicity define "SDE Ethnicity": Patient.ethnicity E return Tuple { codes: { E.ombCategory } union E.detailed, display: E.text } Library Name Name SafeUseofOpioidsConcurrentPrescribingFHIR SDE Ethnicity define "SDE Ethnicity": SDE."SDE Ethnicity" Library Name Name SafeUseofOpioidsConcurrentPrescribingFHIR Intervention Palliative or Hospice Care define "Intervention Palliative or Hospice Care": [ServiceRequest: "Palliative or Hospice Care"] union [Procedure: "Palliative or Hospice Care"] Library Name Name SafeUseofOpioidsConcurrentPrescribingFHIR Denominator Exclusion define "Denominator Exclusion": /*Excludes encounters of patients with cancer or who are receiving palliative or hospice care at the time of the encounter*/ "Inpatient Encounters with an Opioid or Benzodiazepine at Discharge" InpatientEncounter where exists ( [Condition: "All Primary and Secondary Cancer"] Cancer where ( Cancer.isProblemListItem ( ) or Cancer.isHealthConcern ( ) ) and Cancer.isActive ( ) and Cancer.prevalenceInterval ( ) overlaps InpatientEncounter.period ) or exists ( ( InpatientEncounter.encounterDiagnosis ( ) ) InpatientEncounterDiagnosis where InpatientEncounterDiagnosis.code in "All Primary and Secondary Cancer" ) or exists ( "Intervention Palliative or Hospice Care" PalliativeOrHospiceCare where Coalesce(PalliativeOrHospiceCare.performed.toInterval(), PalliativeOrHospiceCare.authoredOn.toInterval()) during day of CQMCommon."HospitalizationWithObservation" ( InpatientEncounter ) ) or ( InpatientEncounter.hospitalization.dischargeDisposition in "Discharge To Acute Care Facility" or InpatientEncounter.hospitalization.dischargeDisposition in "Hospice Care Referral or Admission" or InpatientEncounter.hospitalization.dischargeDisposition in "Patient Expired" ) Library Name Name SupplementalDataElements SDE Race define "SDE Race": Patient.race R return Tuple { codes: R.ombCategory union R.detailed, display: R.text } Library Name Name SafeUseofOpioidsConcurrentPrescribingFHIR SDE Race define "SDE Race": SDE."SDE Race"
define "SDE Sex": case when Patient.gender = 'male' then Code { code: 'M', system: 'http://hl7.org/fhir/v3/AdministrativeGender', display: 'Male' } when Patient.gender = 'female' then Code { code: 'F', system: 'http://hl7.org/fhir/v3/AdministrativeGender', display: 'Female' } else null end
define "Inpatient Encounter": [Encounter: "Encounter Inpatient"] EncounterInpatient where EncounterInpatient.status = 'finished' and EncounterInpatient.period ends during day of "Measurement Period"
Inpatient Encounter with Age Greater than or Equal to 18
define "Inpatient Encounter with Age Greater than or Equal to 18": CQMCommon."Inpatient Encounter" InpatientHospitalEncounter where AgeInYearsAt(date from start of InpatientHospitalEncounter.period) >= 18
define "Opioid at Discharge": ( [MedicationRequest: "Schedule II & III Opioid Medications"] OpioidMedications where ( OpioidMedications.isCommunity ( ) or OpioidMedications.isDischarge ( ) ) ) OpioidDischargeMedication where OpioidDischargeMedication.status in { 'active', 'completed' } and OpioidDischargeMedication.intent = 'order'
define "Benzodiazepine at Discharge": ( [MedicationRequest: medication in "Schedule IV Benzodiazepines"] BenzoMedications where ( BenzoMedications.isCommunity ( ) or BenzoMedications.isDischarge ( ) ) ) BenzodiazepineDischargeMedication where BenzodiazepineDischargeMedication.status in { 'active', 'completed' } and BenzodiazepineDischargeMedication.intent = 'order'
define "Numerator": /*Encounters of patients prescribed two or more opioids or an opioid and benzodiazepine at discharge.*/ ( "Inpatient Encounter with Age Greater than or Equal to 18" InpatientEncounter where ( Count("Opioid at Discharge" Opioids return distinct Opioids.medication ) >= 2 ) ) union ( "Inpatient Encounter with Age Greater than or Equal to 18" InpatientEncounter with "Opioid at Discharge" OpioidsDischarge such that OpioidsDischarge.authoredOn during InpatientEncounter.period with "Benzodiazepine at Discharge" BenzodiazepinesDischarge such that BenzodiazepinesDischarge.authoredOn during day of InpatientEncounter.period )
Inpatient Encounters with an Opioid or Benzodiazepine at Discharge
define "Inpatient Encounters with an Opioid or Benzodiazepine at Discharge": "Inpatient Encounter with Age Greater than or Equal to 18" InpatientEncounter with ( "Opioid at Discharge" union "Benzodiazepine at Discharge" ) OpioidOrBenzodiazepineAtDischarge such that OpioidOrBenzodiazepineAtDischarge.authoredOn during day of InpatientEncounter.period
define "Initial Population": "Inpatient Encounters with an Opioid or Benzodiazepine at Discharge"
define "Denominator": "Initial Population"
define "SDE Payer": [Coverage: type in "Payer Type"] Payer return { code: Payer.type, period: Payer.period }
define "SDE Ethnicity": Patient.ethnicity E return Tuple { codes: { E.ombCategory } union E.detailed, display: E.text }
define "SDE Ethnicity": SDE."SDE Ethnicity"
define "Intervention Palliative or Hospice Care": [ServiceRequest: "Palliative or Hospice Care"] union [Procedure: "Palliative or Hospice Care"]
define "Denominator Exclusion": /*Excludes encounters of patients with cancer or who are receiving palliative or hospice care at the time of the encounter*/ "Inpatient Encounters with an Opioid or Benzodiazepine at Discharge" InpatientEncounter where exists ( [Condition: "All Primary and Secondary Cancer"] Cancer where ( Cancer.isProblemListItem ( ) or Cancer.isHealthConcern ( ) ) and Cancer.isActive ( ) and Cancer.prevalenceInterval ( ) overlaps InpatientEncounter.period ) or exists ( ( InpatientEncounter.encounterDiagnosis ( ) ) InpatientEncounterDiagnosis where InpatientEncounterDiagnosis.code in "All Primary and Secondary Cancer" ) or exists ( "Intervention Palliative or Hospice Care" PalliativeOrHospiceCare where Coalesce(PalliativeOrHospiceCare.performed.toInterval(), PalliativeOrHospiceCare.authoredOn.toInterval()) during day of CQMCommon."HospitalizationWithObservation" ( InpatientEncounter ) ) or ( InpatientEncounter.hospitalization.dischargeDisposition in "Discharge To Acute Care Facility" or InpatientEncounter.hospitalization.dischargeDisposition in "Hospice Care Referral or Admission" or InpatientEncounter.hospitalization.dischargeDisposition in "Patient Expired" )
define "SDE Race": Patient.race R return Tuple { codes: R.ombCategory union R.detailed, display: R.text }
Code system USCoreConditionCategoryExtensionCodes
Code system ConditionClinicalStatusCodes
Value set Schedule II & III Opioid Medications
Value set All Primary and Secondary Cancer
Value set Discharge To Acute Care Facility
Value set Hospice Care Referral or Admission
Safe Use of Opioids - Concurrent PrescribingFHIR
Centers for Medicare & Medicaid Services (CMS)
Proportion of inpatient hospitalizations for patients 18 years of age and older prescribed, or continued on, two or more opioids or an opioid and benzodiazepine concurrently at discharge
Clinician judgement, clinical appropriateness, or both may indicate concurrent prescribing of two unique opioids or an opioid and benzodiazepine is medically necessary, thus the measure is not expected to have a zero rate. Inpatient hospitalizations with discharge medications of a new or continuing opioid or a new or continuing benzodiazepine prescription should be included in the initial population. Inpatient hospitalizations with discharge medications of two or more new or continuing opioids or new or continuing opioid and benzodiazepine resulting in concurrent therapy at discharge should be included in the numerator. Each benzodiazepine and opioid included on the medication discharge list is considered a unique prescription. The denominator population includes patients with inpatient hospitalizations and patients from Acute Hospital Care at Home programs, who are treated and billed as inpatients but receive care in their home. This eCQM is an episode-based measure. An episode is defined as each inpatient hospitalization or encounter that ends during the measurement period. This FHIR-based measure has been derived from the QDM-based measure: CMS506v6. Please refer to the HL7 QI-Core Implementation Guide (http://hl7.org/fhir/us/qicore/index.html) for more information on QI-Core and mapping recommendations from QDM to QI-Core 4.1.1 (http://hl7.org/fhir/us/qicore/qdm-to-qicore.html).
Limited proprietary coding is contained in the Measure specifications for user convenience. Users of proprietary code sets should obtain all necessary licenses from the owners of the code sets. Mathematica disclaims all liability for use or accuracy of any third party codes contained in the specifications. CPT(R) contained in the measure specifications is copyright 2004-2022 American Medical Association. LOINC(R) copyright 2004-2022 Regenstrief Institute, Inc. This material contains SNOMED Clinical Terms(R) (SNOMED CT[R]) copyright 2004-2022 International Health Terminology Standards Development Organisation. ICD-10 copyright 2022 World Health Organization. All Rights Reserved.
These performance measures are not clinical guidelines, do not establish a standard of medical care, and have not been tested for all potential applications. THE MEASURES AND SPECIFICATION ARE PROVIDED AS IS WITHOUT WARRANTY OF ANY KIND. Due to technical limitations, registered trademarks are indicated by (R) or [R] and unregistered trademarks are indicated by (TM) or [TM].
Unintentional opioid overdose fatalities have become a major public health concern in the United States (Rudd et al., 2016). Reducing the number of unintentional overdoses has become a priority for numerous federal organizations including, but not limited to, the Centers for Disease Control and Prevention (CDC), the Federal Interagency Workgroup for Opioid Adverse Drug Events, and the Substance Abuse and Mental Health Services Administration. Concurrent prescriptions of opioids or opioids and benzodiazepines places patients at a greater risk of unintentional overdose due to the increased risk of respiratory depression (Dowell, Haegerich, & Chou, 2016 and Dowell, Ragan, Jones, Baldwin, & Chou, 2022). An analysis of national prescribing patterns shows that more than half of patients who received an opioid prescription in 2009 had filled another opioid prescription within the previous 30 days (National Institute on Drug Abuse, 2011). Studies of multiple claims and prescription databases have shown that between 5%-15% of patients receive concurrent opioid prescriptions and 5%-20% of patients receive concurrent opioid and benzodiazepine prescriptions across various settings (Liu et al., 2013; Mack et al., 2015, Park et al., 2015). Patients who have multiple opioid prescriptions have an increased risk for overdose (Jena et al., 2014). Rates of fatal overdose are ten times higher in patients who are co-dispensed opioid analgesics and benzodiazepines than opioids alone (Dasgupta et al., 2015). The number of opioid overdose deaths involving benzodiazepines increased 14% on average each year from 2006 to 2011, while the number of opioid analgesic overdose deaths not involving benzodiazepines did not change significantly (Jones & McAninch, 2015). Furthermore, concurrent use of benzodiazepines with opioids was prevalent in 31%-51% of fatal overdoses (Dowell, Haegerich, & Chou, 2016). One study found that eliminating concurrent use of opioids and benzodiazepines could reduce the risk of opioid overdose-related emergency department (ED) and inpatient visits by 15% and potentially could have prevented an estimated 2,630 deaths related to opioid painkiller overdoses in 2015 (Sun et al., 2017). A study on The Opioid Safety Initiative in the Veterans Health Administration (VHA), which includes an opioid and benzodiazepine concurrent prescribing measure that this measure is based on, was associated with a decrease of 20.67% overall and 0.86% patients per month (781 patients per month) receiving concurrent benzodiazepine with an opioid among all adult VHA patients who filled outpatient opioid prescriptions from October 2012 to September 2014 (Lin et al., 2017). Adopting a measure that calculates the proportion of patients with two or more opioids or opioids and benzodiazepines concurrently has the potential to reduce preventable mortality and reduce the costs associated with adverse events related to opioid use by (1) encouraging providers to identify patients with concurrent prescriptions of opioids or opioids and benzodiazepines and (2) discouraging providers from prescribing two or more opioids or opioids and benzodiazepines concurrently.
The CDC Clinical Practice Guideline for Prescribing Opioids for Pain — United States, 2022 recommends that clinicians should: - “[Use strategies minimizing] opioid use…for both opioid-naïve and opioid-tolerant patients with acute pain when possible. If patients receiving long-term opioid therapy require additional medication for acute pain, nonopioid medications should be used when possible.” - ”Use particular caution when prescribing opioid pain medication and benzodiazepines concurrently." - “Review increased risks for respiratory depression when opioids are taken with benzodiazepines, other sedatives, alcohol, nonprescribed or illicit drugs (e.g., heroin), or other opioids (see Recommendations 8 and 11)” - “Closely monitor patients who are unable to taper and who continue on high-dose or otherwise high-risk opioid regimens (e.g., opioids prescribed concurrently with benzodiazepines) and should work with patients to mitigate overdose risk (e.g., by providing overdose education and naloxone) (see Recommendation 8).” - "Discuss information from the PDMP with the patient and confirm that the patient is aware of any additional prescriptions.” - “Discuss safety concerns, including increased risk for respiratory depression and overdose, with patients found to be receiving overlapping prescription opioids from multiple clinicians who are not coordinating the patient’s care or patients who are receiving medications that increase risk when combined with opioids (e.g., benzodiazepines) (see Recommendation 11), and offer naloxone (see Recommendation 8). - "Discuss safety concerns with other clinicians who are prescribing controlled substances for the patient. Ideally, clinicians should first discuss concerns with the patient and inform them that they plan to coordinate care with their other clinicians to improve the patient’s safety.” In addition to the 2022 CDC Clinical Practice Guideline for Prescribing Opioids for Pain, opioid prescribing guidelines issued by various state agencies and professional societies for various settings agree with the recommendation to avoid concurrently prescribing opioids (American Academy of Emergency Medicine and Washington Agency Medical Directors’ Group (WAMDG)), and opioids and benzodiazepines (WAMDG, American Society of Interventional Pain Physicians, and New York City Department Of Health and Mental Hygiene) whenever possible as the combination of these medications may potentiate opioid-induced respiratory depression.
Proportion of inpatient hospitalizations for patients 18 years of age and older prescribed, or continued on, two or more opioids or an opioid and benzodiazepine concurrently at discharge.
Inpatient hospitalizations (inpatient stay less than or equal to 120 days) that end during the measurement period, where the patient is 18 years of age and older at the start of the encounter and prescribed one or more new or continuing opioid or benzodiazepine at discharge
Inpatient hospitalizations where patients have cancer that begins prior to or during the encounter or are ordered or are receiving palliative or hospice care (including comfort measures, terminal care, and dying care) during the hospitalization or in an emergency department encounter or observation stay immediately prior to hospitalization, patients discharged to another inpatient care facility, and patients who expire during the inpatient stay.
Inpatient hospitalizations where the patient is prescribed or continuing to take two or more opioids or an opioid and benzodiazepine at discharge